Reducing the Risk of Healthcare Associated Infections

The Role of Antimicrobial Copper Touch Surfaces

CDA Publication 196

2013

Reducing the Risk of Healthcare Associated Infections

The Role of Antimicrobial Copper Touch Surfaces
CDA Publication 196
October 2013

Contents
1. Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Scientific Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Laboratory Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Antibacterial efficacy test standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Test protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mode of action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Copper tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preventing the spread of antibiotic resistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

US EPA Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Key features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Registered claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Dermatology and neonatal ICU study, Kitasato University Hospital study, Japan . . . . . . . . . . . . . .
General medical ward study, Selly Oak Hospital, UK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outpatient clinic study, US. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ICU clinical trial, multi-site, US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Practical Aspects of Implementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Range of Alloys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Fabricability, Durability and Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Guidance on Cleaning and Disinfection of Antimicrobial Copper Alloys. . . . . . . . . . . . . . . . 7
Cost and Cost-benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Sustainability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Availability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specifying Copper and Copper Alloy Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

5. Background Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Learning More . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Copper Voluntary Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
About Copper Development Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

6. Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Efficacy - Laboratory Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Efficacy - EPA Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Efficacy - Clinical Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Mode of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Health Economics Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Copper Voluntary Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Appendix 1: YHEC Business Case Model Worked Example - Intensive Care Unit, UK . . . . . 12

1. Executive Summary
Copper, as well as being mans oldest engineering metal, is now
recognised as a proven, broad-spectrum antimicrobial material. Well
over 60 published papers support the efficacy of copper against
pathogens that cause healthcare associated infections (HCAIs) both
in the laboratory and the busy clinical environment. Whilst this is a
secondary function, it is intrinsic to both copper and copper alloys,
like brass and bronze, and will persist throughout the lifetime of any
component manufactured from them. Hundreds of alloys from this
well-known family of industrial materials are now collectively
referred to as antimicrobial copper.
There is growing proof that contamination in the hospital
environment, especially close to the patient, plays a significant role
in the acquisition of HCAIs. This has been investigated with respect
to antimicrobial copper and there is now evidence demonstrating a
link between the installation of copper alloy touch surfaces and
reduced infection rates. As the body of published scientific evidence
has grown, antimicrobial copper has begun to be included in
infection control guidelines and hospital specifications e.g. in India,
Chile and Poland.
Studies on the mechanisms by which copper exerts its influence
have resulted in a better understanding of the materials potential.
Importantly, the combination of multiple pathways plus the rapid
destruction of bacterial DNA means the development of resistance
to copper on solid metal surfaces is extremely unlikely. In addition,
coppers ability to destroy microbial genomic material suggests that
copper alloy surfaces may also play an important role in reducing
the spread of antibiotic resistant organisms.
The UK clinical trial at Selly Oak Hospital was the first in the world
to publish results demonstrating coppers efficacy in reducing
microbial contamination in a clinical setting by >90%. This has
since been confirmed by many other trials around the world.
In the US, a seminal three-centre, three-and-a-half year study has
been performed in an ICU environment, resulting in a number of
papers to date. Published results show a reduction in microbial
burden of >80% and an associated reduction in HCAIs of >50%
following a limited copper intervention. Moreover, such an

intervention requires no special training, additional cleaning or staff

monitoring and causes no disruption to the hospital routine.
The University of York, well recognised as a leader in health
economics research, has developed a cost-benefit model that allows
the input of local data. The default data entered by York for a
20-bed ICU predicts payback in less than one year.
The increasing awareness of the antimicrobial characteristics of
copper has convinced manufacturers to develop new products using
copper alloys - from sink and door hardware through standard ward
fittings to stretcher and hospital beds - and the number of suppliers
is growing. Copper and its industrial alloys are easy to form into
long-lasting products, suitable for service in the healthcare
environment. Whole life costs are comparable with other materials
and products are fully recyclable, so contribute to sustainable
design. Alloys that look like stainless steel are available, although
the distinctive golds and bronzes can provide a highly visible
statement that an additional measure is being taken to reduce the
risk of HCAIs.
The use of copper for touch surfaces is not a substitute for
standard hygiene practices and products should be cleaned and
disinfected according to standard procedures, using standard
agents. Some surface oxidation (slight darkening) can take place,
depending on the alloy, but this does not affect efficacy. Feedback
from clinical trials shows that patients and staff found the change
in appearance acceptable.
Information, training and support are available from industry trade
bodies to all stakeholders, on both the supply and demand side, for
the manufacture, specification and correct deployment of copper
and copper alloy products. An industry stewardship scheme,
comprising the Antimicrobial Copper brand and Cu+ mark, has been
established to approve efficacious alloys and applications based on
the latest scientific evidence.
Adoption of antimicrobial copper touch surfaces as an additional
measure to supplement current infection control practices has
already started in hospitals and care homes around the world.

2. Introduction
Well before microorganisms were discovered, the Egyptians, Greeks,
Romans and Aztecs used copper-based preparations to treat burns,
sore throats and skin rashes, as well as for day-to-day hygiene.
Copper was also used to ward off infection in battlefield wounds.
In the 19th century, with the discovery of the cause-and-effect
relationship between germs and the development of disease, scientific
evidence started to be gathered. In the last few decades, extensive
research has been carried out on the antimicrobial properties of copper
and its alloys against a range of microorganisms threatening public
health in food processing, healthcare and air conditioning applications.
A summary of the main results is presented here and key papers are
listed in the Bibliography.

3. Scientific Evidence
Laboratory Studies
Research has been carried out to determine the survival of different
microorganisms on copper and copper alloy surfaces. Much of this
work since 1994 has been carried out by Prof Bill Keevil, Chair in
Environmental Healthcare and Principal Investigator (Microbiology
and Environmental Health) at the University of Southampton. The
results have been verified in laboratories around the world including
the UK (Aston and Kingston Universities), US, South Africa, Germany
and Japan.

Copper has been shown to destroy microbes rather than merely

prevent their growth, and efficacy has been shown against the key
organisms threatening public health today, some of which are listed
on this page.

Antibacterial efficacy test standards

ISO 22196, based on the Japanese standard JIS Z2801, is most
commonly used in the certification of antimicrobial efficacy of hard
surfaces. However this test is carried out at 35oC and >90%
humidity and so is not an appropriate indicator of efficacy under
typical indoor conditions for touch surface applications. This has
been recognised by The Organisation for Economic Co-operation and
Development (OECD) Working Party on Chemicals, Pesticides and
Biotechnology, who have warned of the danger of using this test to
evaluate materials that will be used under other conditions. The
more appropriate US Environmental Protection Agency approved
test, carried out at room temperature and humidity, is being
developed into a standard by ASTM and also as a British Standard.

Test protocols
The University of Southampton uses a similar test: 1 x 1 cm2
samples of each alloy were inoculated with high challenges (107) of
bacteria in a soil-loaded suspension and incubated at either 20C or
4C for various time periods. Standard microbiological techniques
were used to culture, recover and enumerate the viable bacteria and
direct microscopy methods were used to assess membrane integrity
and respiration. This test has also allowed comparison between
copper alloys, triclosan and commercial silver-containing materials.

Acinetobacter baumannii

Results

Adenovirus

Candida albicans

Figures 1 to 3 show sample data for efficacy of different materials

(copper, copper alloys and silver-containing materials) against MRSA.
Stainless steel is used as the control.

Campylobacter jejuni

Carbapenem-resistant Enterobacteriaceae (CRE)

Clostridium difficile (including spores)

Enterobacter aerogenes

General conclusions for all organisms tested under the wet simulation
protocol, simulating a sneeze or a splash, are summarised below:
I

Results show that bacteria survive on stainless steel for days

and are eliminated on 99% copper in less than 90 minutes
(107 cfu/coupon) at room temperature (Figure 1).

Escherichia coli O157:H7

The effect is slower at 4C but still significant.

Helicobacter pylori

Greatest efficacy is seen in alloys with copper contents >60%.

Influenza A (H1N1)

Klebsiella pneumoniae

Legionella pneumophila

Reduced inoculum testing shows that, at levels of bacterial

challenge typically encountered in the clinical environment
(approx.103 cfu/cm2), kill times were as rapid as 15 minutes
(Figure 2).

Listeria monocytogenes

Mycobacterium tuberculosis

Silver- and triclosan-containing coatings showed no

antimicrobial efficacy at room temperature and humidity and
behaved the same as the stainless steel control (Figure 3).

Norovirus or Norwalk-like virus

Poliovirus

Pseudomonas aeruginosa

Salmonella enteritidis

Staphylococcus aureus (MRSA, E-MRSA and MSSA)

Vancomycin-resistant enterococcus (VRE)

The test has subsequently been developed to simulate a dry

contamination incident, such as a touch, using a lower inoculum
volume but maintaining the high challenge of bacteria. In this dry
contamination simulation protocol, under typical indoor conditions,
the speed of efficacy is even greater with 6-log reductions of VRE in
less than 10 minutes (Figure 4).
Other test protocols have been developed to assess efficacy against
viruses and fungi.

MRSA viability on copper alloys and stainless steel at 20C

C197 (Cu 99%)

S304 (Stainless Steel)

C240 (Cu 80%)

C770 (Cu 55%)

cfu per ml

Figure 1 - Copper alloys with >60% copper have been shown to be

effective at reducing exceptionally high challenges of bacteria,
including antibiotic resistant strains, under typical indoor
conditions (humidity and temperature).

108
106
104
102
0

60

120

180

240

300

360
Time (mins)

MRSA viability on copper at 20C - reduced inoculum

10 7

10 6

105

10 4

10 3

cfu per coupon

10 8
10 7

Figure 2 - At reduced inoculum challenges, more typical of clinical

environments, copper rapidly eliminated MRSA e.g. 103 cfu in
15 minutes.

10 6
10 5
10 4
10 3
10 2
10 1
0

15

30

45

60
Time (mins)

MRSA viability on copper, silver-and triclosan-coated materials

and stainless steel at room temperature and humidity
C11000 (Cu 99.9%)

S304 (Stainless Steel)

AgB

AgA

TS

cfu per coupon

10 8

Figure 3 - Under typical indoor conditions, silver coatings (AgA,

AgB) and the triclosan coating (TS) behave as the stainless steel
control (S30400) - i.e. they show no antimicrobial activity.

10 6

10 4

Copper (C1100) is effective under these conditions, eliminating 107

MRSA in less than 90 minutes.

10 2

60

120

180

240

300

360
Time (mins)

Rapid kill of vancomycin-resistant Enterococcus faecalis

Stainless steel

Copper

cfu per coupon

10 8
10 7
10 6

Figure 4 - With a dry inoculum, equivalent to touch contamination,

there was a rapid kill with over a 6-log reduction of viable
enterococci in less than 10 minutes on copper alloys.

10 5
10 4
10 3
10 2
10 1

10

12

Time (mins)

Mode of action
These and other published test protocols have also allowed the
investigation of mechanisms providing insight into how copper
exerts its effect. Recent studies, showing very rapid efficacy, also go
some way to explaining why the sequence of events remains unclear.
There are several probably-interacting mechanisms proposed by
which copper kills bacteria, including:
I

Causing leakage of potassium or glutamate through the outer

membrane of bacteria

Disturbing osmotic balance

Binding to proteins that do not require copper

Causing oxidative stress by generating hydrogen peroxide

Degradation of bacterial DNA.

The combination of multiple pathways plus the rapid destruction of

bacterial DNA means the development of resistance to copper is
extremely unlikely. Moreover, copper has been used by man since
the Bronze Age, 10,000 years ago, and no copper resistant human
pathogen has been found to date.

Kill times vary according to organism, strain, type and level of

challenge, copper content of alloy and temperature - being more
rapid at 20C but still with a considerable effect at 4C. Copper and
its alloys exhibit efficacy under typical indoor conditions (humidity
and temperature), unlike silver-containing materials and triclosan
which showed no antimicrobial efficacy under these conditions.
Current theories on the mode of action make the development of
copper resistance extremely unlikely.

US EPA Registration
An existing US Environmental Protection Agency (EPA) hard surface
disinfectant test protocol was adapted to align with the Keevil
protocol and a raft of tests (>6000 samples in total) was carried out
at an EPA-approved GLP (Good Laboratory Practice) Laboratory.
Results were formally submitted to the EPA to support a registration
of antimicrobial efficacy in 2008, which allowed marketing of
antimicrobial copper products in the US.

Key features
Three test protocols were established to assess:
I

Efficacy as a sanitiser

Residual self-sanitising activity

Continuous reduction of bacterial contaminants.

Copper tolerance
There is a body of literature using the term copper resistance but
actually describing copper tolerance. Such studies have been
conducted on copper compounds, such as copper chloride and
copper sulphate, usually in aqueous solutions and other complex
formulations. It is suggested that the copper compound kill
mechanism differs from that seen on copper alloy surfaces (socalled contact killing) which provide an almost unlimited source of
high concentration copper. This is not the case with compounds in
solution, where the copper concentration is often low, dispersed
and potentially exhaustible. Thus copper resistance observed in
copper compound-containing solutions is more accurately
described as copper tolerance. Copper-tolerant microbes and
bacteria recovered from surfaces in clinical studies, when exposed
to solid copper alloy surfaces, die within minutes, confirming lack
of resistance.

Preventing the spread of antibiotic resistance

A paper published in 2013 reported that the transfer of antibiotic
resistance by horizontal gene transfer between two species of
bacteria can take place on stainless steel but does not occur on
copper and copper alloys due to the destruction of plasmid and
genomic DNA. The authors suggest a role for these materials in
preventing the spread of antimicrobial resistance as well as HCAIs.

Conclusions
Laboratory research on the antimicrobial efficacy of copper and
copper alloys has been carried out and verified at institutions
around the world and results have been peer-reviewed and
published in respected journals. Results demonstrate the rapid,
broad spectrum antimicrobial efficacy of copper and copper alloys
against the most important pathogens - bacteria, viruses and fungi challenging public health.
4

Staphylococcus aureus, Enterobacter aerogenes,

Escherichia coli O157:H7, Pseudomonas aeruginosa, MRSA and VRE
were deposited on alloys ranging from 60% to 100% copper from
two or three separately manufactured batches of each alloy.

Registered claims
Laboratory testing has shown that, when cleaned regularly (bacterial
claims relate specifically to the organisms tested and to >450
specified alloys with copper content >60%):
I

Antimicrobial copper alloys continuously reduce bacterial

contamination, achieving 99.9% reduction within two hours of
exposure.

Antimicrobial copper alloy surfaces kill greater than 99.9% of

Gram-negative and Gram-positive bacteria within two hours of
exposure.

Antimicrobial copper alloy surfaces deliver continuous and

ongoing antibacterial action, remaining effective in killing
greater than 99.9% of bacteria within two hours, even after
repeated wet and dry abrasion and re-contamination.

Antimicrobial copper alloy surfaces kill greater than 99.9% of

bacteria within two hours, and continue to kill more than 99%
of bacteria even after repeated contamination.

Antimicrobial copper alloy surfaces help inhibit the build up

and growth of bacteria within two hours of exposure between
routine cleaning and sanitising steps.

The EPA registration states about the registered alloys:

These products have been rigorously tested and have demonstrated
antimicrobial activity. After consulting with independent organizations the
Association for Professionals in Infection Control and Epidemiology and the
American Society for Healthcare Environmental Services as well as a leading
expert in the field (Dr. William A. Rutala, Ph.D., M.P.H., University of North
Carolina (UNC) Health Care System and UNC School of Medicine), the Agency
has concluded that the use of these products could provide a benefit as a
supplement to existing infection control measures.

The EPA requires that the following statement be included when

making public health claims in the US related to the use of
antimicrobial copper alloys:
The use of a Copper Alloy surface is a supplement to, and not a substitute for,
standard infection control practices; users must continue to follow all current
infection control practices, including those practices related to cleaning and
disinfection of environmental surfaces. The Copper Alloy surface material has
been shown to reduce microbial contamination, but it does not necessarily
prevent cross contamination.

Conclusions
In the US, antimicrobial products marketed with public health claims
must be registered with the EPA. Copper and copper alloys were the
first solid materials (i.e. not a liquid disinfectant product) to be
registered. Outside the US, this registration represents an
independent, official recognition of the laboratory data presented
and provides the quantified efficacy claims applicable to all
registered alloys for the organisms tested.

Clinical Research
In 1983, a US physician, Dr Phyllis Kuhn, published a hospital study
showing coppers effectiveness in lowering the E. coli count on brass
doorknobs. The study concluded that, if the replacement of brass
with stainless steel was to continue, the frequency of cleaning and
disinfection would need to be increased to control bioburden.

Dermatology and neonatal ICU study, Kitasato University

Hospital study, Japan
In 2005, selected surfaces on a dermatology ward and neonatal
intensive care unit at Kitasato University Hospital, Tokyo, were
wrapped with copper or brass foil and levels of contamination were
monitored on these and control surfaces. It was found that copper
alloys had a superior sanitising effect in the hospital environment.

General medical ward study, Selly Oak Hospital, UK

On the recommendation of the UK Department of Health on
reviewing the laboratory evidence of Keevil et al, a trial was initiated
to investigate efficacy in a dynamic and challenging clinical
environment. Copper Development Association (CDA) provided an
education grant to University Hospitals Birmingham NHS Foundation
Trust and Prof Tom Elliott developed a unique cross-over study at
Selly Oak Hospital, Birmingham. CDA worked with the supply chain
to provide copper products for the trial and also provided liaison
with other clinical trial groups around the world.
From March 2007 onwards, surfaces identified by a multidisciplinary
team as frequently touched on a busy general medical ward were
replaced with copper-containing items and the contamination on

their surfaces compared to control items on the same ward. The

domestic staff followed their standard ward-cleaning timetable.
The copper-containing items introduced included grab rails, door
handles, door push plates, light switches, taps, over-bed tables, sink
traps and toilet seats.
In the first phase of this study, three items were sampled - taps,
door push plates and toilet seats. Sampling took place once a week
for five weeks and then copper and control products were swapped
over to compensate for any bias of use and sampling continued for
a further five weeks. The results show that there was a reduction in
contamination of between 90 and 100% on the copper-containing
items compared to the controls.
In the second, extended, phase, further products were introduced
(including trolleys, light pulls, flush handles, over-bed tables,
dressing trolleys and commode chairs) and these were sampled for
six months, with a crossover at the midway point. Results
demonstrated lower levels of microorganisms on the copper
compared to the standard surfaces - 8 out of the 14 copper surfaces
had significantly reduced bacterial load compared to controls and
the other 6 copper surfaces demonstrated a trend towards reduction
without reaching statistical significance. Furthermore, copper items
were less frequently colonised with VRE, MSSA, MRSA and coliform
bacteria compared to control items (significance was not reached
with MRSA).
In order to assess for any development of resistance to copper, isolates
of VRE, MSSA, MRSA and coliforms recovered from the copper surfaces
were assessed. No resistance to copper was observed.

Outpatient clinic study, US

A study in a US outpatient clinic compared the microbial
contamination on phlebotomy chair arms and an associated
equipment tray. Results showed the copper significantly reduced
the total median bioburden by 90% on the top surface of the arms
and by 88% on the trays.

ICU clinical trial, multi-site, US

The US Department of Defense funded a large-scale three-centre,
intention-to-treat, randomised control trial, conducted at The Medical
University of South Carolina, Charleston (MUSC), The Ralph H Johnson
Veterans Administration Medical Center, Charleston, South Carolina and
The Memorial Sloan-Kettering Cancer Center in New York City.
The aim of the study was to assess coppers antimicrobial efficacy in
intensive care units (ICUs). The institutions replaced stainless steel,
aluminium and plastic touch surfaces with antimicrobial copper
alloys (hereafter referred to as copper in this section) on the
following frequently-touched objects within selected rooms in each
of the ICUs: nurses call devices, monitor bezels, bed rails, chairs, IV
poles, data input devices (computer mice, laptop keyboard bases),
arms of the patient visitors chair and over-bed tables.
During the trial period, the level of bacterial contamination
(bioburden) on matched copper and non-copper surfaces was
determined weekly. No changes were made to clinical practices or
cleaning regimes in the study rooms. The trial, conducted by
infectious disease clinicians and led by Dr Michael Schmidt,
Professor and Vice Chair of the Microbiology and Immunology
Department at MUSC, was executed in three stages.
5

The first stage established the baseline microbial burden on the

frequently-touched objects in ICU rooms before installation of the
copper products. The average microbial burden of the rooms was
found to be 16,885 colony forming units (cfu) per 100 cm2. The
key surfaces shown to be most contaminated and, not surprisingly,
in closest proximity to patients and visitors, were replaced with
copper components.
The second stage was the replacement of the most contaminated
touch surfaces with copper and subsequent comparison of the
microbial burden on these and non-copper equivalent surfaces over
a period of 135 weeks. Eight rooms were upgraded with copper and
matched with control rooms across the three sites. The first paper
published reported the average bioburden observed on copper
surfaces was 83% less than on the non-copper surfaces (465 vs.
2,674 cfu/100 cm2; P = <0.0001, see Figure 5).
Another showed the importance of the hospital bed rails as
reservoirs of contamination and that standard rails became recontaminated significantly more rapidly than copper after
disinfection (at 6.5 hours 434 vs. 5,198 cfu/100 cm2; P = 0.002).
The third stage assessed the incidence of healthcare associated
infections in ICU rooms with and without copper products. During
the patient phase, 650 randomly assigned admissions were studied
throughout 104 weeks. The number of copper components in the
individual rooms was recorded throughout each patients stay, e.g.
whether or not the patient was in a bed with copper rails (bariatric
patients needed special beds, which were not available with copper
rails). Patients were allocated to rooms randomly and their medical
condition was assessed according to APACHE II scores. A
retrospective assessment of records by clinicians, blinded to patient
status, assessed whether individuals contracted an HCAI.
The key paper from this phase was published in an ICHE Special
Topic Issue: The Role of the Environment in Infection Prevention in
May 2013: Copper Surfaces Reduce the Rate of Healthcare-Acquired
Infections in the Intensive Care Unit. It reports a greater than 50%
reduction in HCAIs associated with copper rooms. Statistically this
reflects a reduction in HCAIs in patients cared for in copper rooms
versus standard rooms 10 (3.40%) vs. 26 (8.12%); P = 0.013).
Sustained reduction of microbial burden on hospital surfaces
through introduction of copper
Copper

The paper also reports a significant association between level of

contamination and HCAI risk, with 89% of HCAI occurring among
patients cared for in a room with a bioburden >500 cfu/100cm2;
P =0.038 (regardless of the presence/absence of copper). See Figure 6.
Other papers from this study are in preparation and those already
published have already instigated a number of discussions about
larger trials in Europe and elsewhere.
In summary:
I

In the test ICUs, touch surfaces were shown to serve as

significant microbial reservoirs that could transfer microbes
between patients, healthcare workers and visitors, despite
regular cleaning.

Objects upgraded with copper or copper alloys consistently had

bacterial burdens >80% less than equivalent objects and
below the proposed safe value of 2.5 cfu/cm2.

During the course of the two year study, the minimal observed
oxidation did not reduce the efficacy of the copper.

Limited placement of copper surfaces significantly reduced the

rates of HCAI (by greater than 50%).

The copper surfaces were shown to work in tandem with

standard infection prevention practices to significantly reduce
burden and HCAIs.

Preliminary analysis indicates that rate of infection reduction

was linked to exposure frequency.

Use of copper surfaces represents the first instance where an

intervention designed to reduce burden has had a clinical
impact among ICU patients.

Other trials
Trials have taken place, or are under way, in Chile, China, France,
Germany, Greece, India, Japan, South Africa, Spain and the US.
Quartile distribution of HCAIs stratified by microbial burden

Control

Average cfu per 100 cm2

7,000

HCAIs acquired during patient stay

6,000

18

17

16

20%

14

5,000

12
4,000

10
8

3,000

6
7%

2,000

8
9%

10
13%

4
1,000

250 cfu/100 cm2

Level of risk
Bed rails

IV poles

Chair
arms

Over-bed Monitors Nurse call

tables

Figure 5 - Sustained reduction of microbial burden on common hospital surfaces

through introduction of copper. Proposed hygiene standard level is indicated in orange.
Schmidt M G et al, JCM. 2012.

2
0

<500

500-2,000

2,001-8,000

>8,000

Microbial burden, cfu/100 cm2

Figure 6 - Quartile distribution of HCAIs stratified by microbial burden measured in the

intensive care unit room during the patients stay. There was a significant burden
association between burden and HCAI risk with 89% of HCAIs occurring among patients in
rooms with a burden of more then 500 cfu/100 cm2. Salgado et al, ICHE, 2013.

Conclusions
Teams around the world have led clinical trials to assess coppers
role in reducing bioburden in the clinical environment and any
associated improvement in patient outcomes.
The continuous antimicrobial activity of copper surfaces in
challenging clinical environments has been confirmed. With
standard cleaning and disinfection routines in both copper and
control rooms, copper surfaces are reported to harbour 80% less
microbial burden than controls.
Published data from the first study to assess the impact of replacing
key touch surfaces in ICUs with copper, shows an associated
reduction in the risk of acquiring an HCAI of >50%.

Disinfectant products containing metal ion chelators, such as

EDTA, should be avoided, as these partially and temporarily inhibit
coppers efficacy.
1) Hospital detergents these will clean grease and other soil from
surfaces and should always be used prior to disinfection.
I

Most cleaning products are proprietary and will have

instructions for use always refer to manufacturers
instructions.

Items should be cleaned, dried (disinfected as necessary) and

inspected before use.

If applying disinfectant after normal cleaning, it is common to

wash with clean water and dry between these steps to ensure
optimum activity of disinfectant.

Cleaning wipes are single-use products and should be disposed

of after use.

Some products may combine disinfectants with detergents and

allow single step use.

4. Practical Aspects of Implementation

Range of Alloys
The materials chosen for clinical trials are those already in
common use for other purposes and are readily available to
equipment manufacturers supplying healthcare components. They
represent a range of compositions based on the US EPA-registered
alloys.

Fabricability, Durability and Appearance

Copper alloys, especially brass, have become an industrial standby
due to their ease of use and durability. Much equipment is
manufactured in these materials and subsequently lacquered or
chrome or nickel plated. Brass is readily cast, is considered the gold
standard in terms of machining and is easy to manipulate by
bending and pressing. Moreover, the alloys are very malleable,
which has the potential to allow designers to provide hygienic, as
well as practicable, equipment. Components are familiar, easy to
install and have long service lives.
Copper forms an alloy with a number of other elements such as iron,
zinc, nickel and aluminium, providing a family of alloys with material
characteristics that are readily understood by engineering designers.
The alloys exhibit a range of colours, again allowing expression of
design as well as practicality. Because some are notably different,
they can potentially provide a mark of change and innovation in
healthcare.

Guidance on Cleaning and Disinfection of

Antimicrobial Copper Alloys
Antimicrobial copper surfaces are a supplement to, and not a
substitute for, standard infection control practices and users should
continue to follow all current infection control practices, including
those related to cleaning and disinfection of environmental surfaces.
Copper and copper alloys are active surfaces and may develop an
oxide called a patina over the course of 2 4 weeks if washed and
cleaned using standard healthcare agents and protocols. Once
established, the patina is stable and protects the component from
further oxidation unless it comes into contact with strong reagents.
The developed patina does not reduce efficacy according to results
from laboratory testing and clinical trials.
There are three types of cleaning products to consider see
below. For any product specific information, it is recommended
that the manufacturer is contacted.

2) Hospital disinfectants - will disinfect the surface of the copper

and generally contain:
I

Alcohols - not corrosive to copper alloys but not active against

all microbes.

Bleaches - containing chlorine or with the active ingredient

sodium hypochlorite; the solution is not corrosive to copper
alloys when used correctly.

Quaternary ammonium such compounds do not damage

copper alloys.

Ammonium chloride - is of little concern for copper when used

in normal dilute formulations.

Phenol and ammonia - are rarely used organic chemicals and

not harmful to copper.

Other disinfection techniques:

I

Hydrogen peroxide (solution or vapour - HPV) has no long-term

effect on copper alloys.

Steam may be used for cleaning or disinfection and will not

harm copper alloys.

Formaldehyde is sometimes used for laboratory disinfection and

fumigation and is not deleterious to copper or copper alloys.

3) Metal polishes and cleaners - will brighten the appearance of the

copper and copper alloys.
I

Citric acid based cleaners are preferred as they disinfect and

remove tarnish without leaving a residue.

Proprietary polishing products, such as Brasso, will clean the

copper but are not recommended as they may leave a residual
film which inhibits the antimicrobial effect of copper for a
period of time. Removal of waxes can be difficult but may be
achieved with alcohol wipes.
7

Cost and Cost-benefit

Design

A significant issue with the copper proposition is that, by its

nature, it is a capital investment but one that could improve
patient outcomes and therefore reduce the cost of care. This
means that the costs and benefits accrue in different budgetary
areas. As a world leader in health economics, the University of
Yorks York Health Economics Consortium (YHEC) has carried out a
research project, assessing relevant clinical evidence in western
Europe and the US, and has developed a model illustrating the
cost-benefit of a copper alloy intervention.

Copper alloys are considered by many designers as traditional, and

component designs often reflect a focus on a nostalgic market. In
fact, they provide a great opportunity to design out infection
through the use of modern manufacturing technology. The UK still
plays an important part in the global industry, providing designs that
can best be made using skills and equipment relevant to any
countrys supply chain. The clean, straight stainless steel design
forms that have become so ubiquitous have arisen largely because
the early steels were difficult to fabricate.

The YHEC model allows input of local cost data for fixtures,
fittings and other medical equipment, as well as care costs.
Default data entered by YHEC, based on their research and
commercial costs, shows that targeted installation of
antimicrobial copper will pay back in well under one year,
assuming the project is part of a planned refurbishment or
upgrade (see Appendix 1 for the models assumptions and a
worked example).

Availability

Copper and its alloys are sometimes perceived as expensive,

however, they continue to be widely used throughout industry
because they offer good value. Most of a component cost comes
not from the intrinsic material value, but a combination of
fabrication and fitting costs. Copper alloys are widely used for
complex components, like a tap or a lock, because they are easy to
fabricate, by casting, rolling, machining and then polishing. Fitting
costs are broadly the same for any given component. Copper alloy
components therefore represent a comparable capital cost to
other widely used materials. Installation of a ward set of key
touch surface components is relatively easy and can be
accomplished without major disruption on the ward. Prof Tom
Elliott, leader of the Selly Oak research, has stated that the cost
of fitting out the 20-bed trial ward was equivalent to the cost of
just one-and-a-half infections.

Adoption
Since the publication of the bioburden reduction results from the
Selly Oak trial, hospitals and care homes in the UK and the rest of
the world have started to install antimicrobial copper touch
surfaces in refurbishment and new-build projects and some of
these are already specifying additional installations.
Installations in Europe to date include a cystic fibrosis unit for
young adults at Northern General Hospital, Sheffield, an ICU at
Trafford General, Manchester, a care home in Mullingar, Ireland, a
multi-generational care home in Laval, France, a childrens ICU in
Aghia Sophia Paediatric Hospital, Greece, a nephrology
department, Poland and a geriatric ward at Evangelisches
Geriatriezentrum, Berlin. These projects illustrate the variety of
hospital types, ward types and different healthcare systems in
Europe where antimicrobial copper has been installed.

Sustainability
Copper is 100% recyclable without loss of properties. Scrap from
manufacturing has value and there is a very well developed
infrastructure for collecting and recycling it. In Europe, over 40%
of copper needs are met through the recycling route and almost
all the brass produced comes from recycled stock. According to a
recent paper from the Fraunhofer Institute, two thirds of copper
mined since 1900 is still in productive use today.
8

Copper alloys are widely available from both primary manufacturers

and stockists. Manufacturers of components have access to a wide
variety of material forms and good selection advice from these
sources, as well as the support of Copper Development Association
(CDA) and the global network of Copper Alliance Copper Centres.
Globally, there are thousands of suppliers of both raw materials and
semi-finished products.

Specifying Copper and Copper Alloy Products

As the global industry representative, the
International Copper Association (ICA) has
developed the Antimicrobial Copper name and
Cu+ mark to ensure it addresses its stewardship
with regard to the deployment of copper and
copper alloys in the field. The use of the
Antimicrobial Copper brand and Cu+ mark by an
organisation indicates that a Copper Centre, on
behalf of ICA, has granted permission to do so based upon
adherence to strict usage rules. These rules guide that
organisations understanding of the underlying technology and the
way they promote, advise and deploy it in line with existing
research, regulatory and legislative requirements. Antimicrobial
Copper is the umbrella term for all Cu+ approved antimicrobial
copper alloys.

Conclusions
Copper and its alloys are readily available and cost-effective to
form into durable equipment and fittings suitable for service in the
healthcare environment. Alloys are available which look like
stainless steel, as well as the distinctive golds and bronzes which
can provide a highly visible statement that an additional measure
is being taken to reduce the risk of HCAIs. Components are
familiar, easy to install and have long service lives. They require no
special training, special cleaning or ongoing maintenance and
provide no disruption to the hospital routine. Products made from
solid materials will remain effective in killing germs throughout
their lives, even if scratched. They are fully recyclable and therefore
contribute to sustainable design. An expanding range of products
is available commercially and deployment of copper in hospitals is
practical and viable.
Using component cost data from recent antimicrobial copper
installations in European hospitals and published cost of care figures
for the UK, upgrading an ICU as part of a new-build or planned
refurbishment results in a payback of less than one year, according
to the YHEC model.

The use of copper for touch surfaces is not a substitute for standard
hygiene practices and products should be cleaned and disinfected
according to standard procedures, using standard agents. Some
acceptable surface oxidation (slight darkening) will take place but
this does not affect efficacy.
The Antimicrobial Copper name and Cu+ mark form the core of a
stewardship programme and have been established to provide a focus
for all stakeholder needs. This includes local training and advice on
both the science and practical application of antimicrobial copper.

5. Background Information
Learning More
CDA is able to offer support by providing speakers and advisors for
team meetings, seminars and other events, covering the science and
practical application of antimicrobial copper. All information
resources are also accessible online. See back cover for contact and
website details.

Copper Voluntary Risk Assessment

The industry has undertaken a Voluntary Risk Assessment for copper,
the assessment process for which was agreed with the Italian
Governments Istituto Superiore di Sanit, acting as the review
country on behalf of the European Commission and the EU Member
States. One of the conclusions is that the use of copper products is
in general safe for Europes environment and the health of its
citizens. This statement has been accepted by the European
Commission and EU Member State experts.

About Copper Development Association

CDA is a not-for-profit, membership-based organisation which
supports and promotes the correct and efficient use of copper and
its alloys through the provision of technical support and impartial
information to professionals, end users and students. CDA is part of
a global network of 28 Copper Centres - the Copper Alliance - with a
regional office in Brussels, European Copper Institute, and
headquarters in New York, International Copper Association, Ltd
(ICA). ICA funds the University of Southampton research on
antimicrobial copper.
CDA provided an education grant to University Hospitals
Birmingham NHS Foundation Trust where Prof Tom Elliott developed
a clinical trial. CDA also works with the supply chain to provide
copper products, initially for the Selly Oak trial and subsequently to
meet demand from the market. CDA also provides liaison with other
clinical trial groups around the world.

6. Bibliography
Efficacy - Laboratory Studies

Efficacy - Clinical Studies

Wilks SA, Michels H, Keevil CW. The International Journal of Food

Microbiology 105:445-454 (2005).

Kuhn PJ. Doorknobs: A Source of Nosocomial Infection? Diagnostic Medicine,

Nov/Dec 1983.

Michels HT, Wilks SA, Noyce JO, and Keevil CW. The Survival of E.coli O157 on
a Range of Metal Surfaces. Copper Alloys for Human Infectious Disease
Control, Presented at Materials Science and Technology Conference,
September 25-28, 2005, Pittsburgh, PA, Copper for the 21st Century
Symposium.

Sasahara T, Niiyama N and Ueno M. Use of Copper and its Alloys to Reduce
Bacterial Contamination in Hospitals (Invited lecture), Journal of the JRICu
Vol.46 No.1 (2007).

Noyce JO, Michels H and Keevil CW. Potential use of copper surfaces to
reduce survival of epidemic Methicillin-resistant Staphylococcus aureus in
the healthcare environment. Journal of Hospital Infection, Vol. 63, Issue 3,
pp. 289-297, July 2006.
Wilks SA, Michels HT and Keevil CW. Survival of Listeria monocytogenes
Scott A on metal surfaces: Implications for cross-contamination.
International Journal of Food Microbiology, 111, September (2006), pp. 93-98,
(external peer review).
Noyce JO, Michels H and Keevil CW. Inactivation of Influenza A Virus on
Copper versus Stainless Steel Surfaces. Applied and Environmental
Microbiology, pp. 2748-2750, Vol. 73, No. 8, April 2007.
Mehtar S, Wiid I and Todorov SD. The antimicrobial activity of copper and
copper alloys against nosocomial pathogens and Mycobacterium tuberculosis
isolated from healthcare facilities in the Western Cape: an in-vitro study.
Journal of Hospital Infection, Vol. 68, Issue 1, pp. 45-51, January 2008.
Wheeldon LJ, Worthington T, Lambert PA, Hilton AC, Lowden CJ and
Elliott TSJ. Antimicrobial efficacy of copper surfaces against spores and
vegetative cells of Clostridium difficile: the germination theory. Journal of
Antimicrobial Chemotherapy (2008) 62, 522-525.
Weaver L, Michels HT and Keevil CW. Survival of Clostridium difficile on
copper and steel: futuristic options for hospital hygiene, Journal of Hospital
Infection, Vol. 68, Issue 2, pp. 145-151, February 2008.
Michels HT, Noyce JO and Keevil CW. Effects of temperature and humidity on
the efficacy of methicillin-resistant Staphylococcus aureus challenged
antimicrobial materials containing silver and copper. Letters in Applied
Microbiology, 2009 August; 49(2): 191195.
Warnes SL, Keevil CW. Inactivation of Norovirus on Dry Copper Alloy
Surfaces. PLoS ONE 8(9): e75017. doi:10.1371/journal.pone.0075017.
S. L. Warnes and C. W. Keevil. Mechanism of copper surface toxicity in
E. Coli O157.H7 and Salmonella involves immediate membrane depolarisation
followed by slower rate of DNA destruction. Appl Environ Microbiol. 2011
September; 77(17): 60496059. doi: 10.1128/AEM.00597-11. PMCID:
PMC3165410.
Sarah L. Warnes, Callum J. Highmore, and C. William Keevil. Horizontal
Transfer of Antibiotic Resistance Genes on Abiotic Touch Surfaces:
Implications for Public Health. doi:10.1128/mBio.00489-12. 3(6): mBio.

Efficacy - EPA Registration

Michels HT and Anderson DG. Antimicrobial regulatory efficacy testing of
solid copper alloy surfaces in the USA. pp 185-190, Metal Ions in Biology and
Medicine: Vol. 10., Eds Ph. Collery, I. Maymard, T. Theophanides, L. Khassanova,
T. Collery. John Libbey Eurotext, Paris 2008.

10

Casey AL, Lambert PA, Miruszenko L and Elliott TSJ. Copper for Preventing
Microbial Environmental Contamination, Poster presented at the Interscience
Conference on Antimicrobial Agents and Chemotherapy (ICAAC), October 2008.
Casey AL, Adams D, Karpanen TJ, Lambert PA, Cookson BD, Nightingale P,
Miruszenko L, Shillam R, Christian P, Elliott TSJ. The role of copper in the
reduction of contamination of the hospital environment, Journal of Hospital
Infection, Volume 74, Issue 1, January 2010, pp. 72-77.
Prado V, Duran C, Crestto M et al. Effectiveness of copper contact surfaces in
reducing the microbial burden (MB) in the intensive care unit (ICU) of
Hospital del Cobre, Calama, Chile. Poster 56.044, 14th International
Conference on Infectious Diseases, Miami, March 11, 2010.
Marais F, Mehtar S and Chalkley L. Antimicrobial efficacy of copper touch
surfaces in reducing environmental bioburden in a South African community
healthcare facility. Journal of Hospital Infection, Volume 74, Issue 1, January
2010, pp. 80-82.
Casey AL, Karpanen TJ, Adams D, Lambert PA, Nightingale P, Miruszenko L,
Elliott TSJ. A comparative study to evaluate the surface microbial
contamination associated with copper-containing and stainless steel pens
utilized by nurses in the critical care unit. American Journal of Infection
Control. 2011, June 9.
Schmidt MG, Copper Touch Surface Initiative Microbiology and Immunology,
Medical University of South Carolina, Charleston, USA, BMC Proceedings
2011, 5(Suppl 6):O53 (Oral presentation delivered at 1st International
Conference on Prevention and Infection Control, June 29-July 2, 2011,
Geneva, Switzerland.
Karpanen TJ, Casey AL, Lambert PA, Cookson BD, Nightingale P, Miruszenko L
and Elliott TSJ. The antimicrobial efficacy of copper alloy furnishing in the
clinical environment; a cross-over study. Infection Control and Hospital
Epidemiology, January 2012, vol. 33, no. 1.
Rai S, Hirsch BE, Attaway HH, Nadan R, Fairey S, Hardy J, Miller G, Armellino
D, Moran WR, Sharpe P, Estelle A, Michel JH, Michels HT and Schmidt MG.
Evaluation of Antimicrobial Properties of Copper Surfaces in an Outpatient
Infectious Disease Practice. Infection Control and Hospital Epidemiology
Vol. 33, No. 2 (February 2012), pp. 200-201, published by: The University of
Chicago Press on behalf of The Society for Healthcare Epidemiology of
America. DOI: 10.1086/663701.
Sharpe PA and Schmidt MG. Control and mitigation of healthcare-acquired
infections: Designing clinical trials to evaluate new materials and technologies.
Health Environments Research & Design Journal, 5(1), 94-115. 2011.
Attaway HH III, Fairey S, Steed LL, Salgado CD, Michels HT, Schmidt MG.
Intrinsic bacterial burden associated with intensive care unit hospital beds:
effects of disinfection on population recovery and mitigation of potential
infection risk. Am J Infect Control. 2012 Dec;40(10):907-12.
doi:10.1016/j.ajic.2011.11.019. Epub 2012 Feb 22.

Schmidt MG, Attaway HH, Sharpe PA, John Jr J, Sepkowitz KA, Morgan A,
Fairey SE, Singh S, Steed LL, Cantey JR, Freeman KD, Michels HT and Salgado
CD. Sustained Reduction of Microbial Burden on Common Hospital Surfaces
through Introduction of Copper. J Clin. Microbiol. 2012, 50(7):2217. DOI:
10.1128/JCM.01032-12. Published Ahead of Print 2 May 2012.
OGorman J, Humphreys H. Application of copper to prevent and control
infection. Where are we now? Journal of Hospital Infection Volume 81, Issue
4, August 2012, pp. 217223
Cassandra D Salgado, MD; Kent A Sepkowitz, MD; Joseph F John, MD;
J Robert Cantey, MD; Hubert H Attaway, MS; Katherine D Freeman, DrPH;
Peter A Sharpe, MBA; Harold T Michels, PhD; Michael G Schmidt, PhD.
Copper Surfaces Reduce the Rate of Healthcare-Acquired Infections in the
Intensive Care Unit. Infection Control and Hospital Epidemiology , Vol. 34,
No. 5, Special Topic Issue: The Role of the Environment in Infection
Prevention (May 2013), pp. 479-486.
Michael G Schmidt, PhD; Hubert H Attaway III, MS; Sarah E Fairey, BS; Lisa L
Steed, PhD; Harold T Michels, PhD; Cassandra D Salgado, MD, MS. Copper
Continuously Limits the Concentration of Bacteria Resident on Bed Rails
within the Intensive Care Unit. Infection Control and Hospital Epidemiology.
Vol. 34, No. 5, Special Topic Issue: The Role of the Environment in Infection
Prevention (May 2013), pp. 530-533.
M G Schmidt. The role of continuous microbial debulking in the hospital
environment and its effect on reducing HCAIs. Chapter from
Decontamination in Hospitals and Healthcare. Edited by J Walker, Public
Health England, UK. Woodhead Publishing Series in Biomaterials No. 62.
(Due for publication November 2013).

Mode of Action
Karlstrom AR and Levine RL. Copper inhibits the protease from human
immunodeficiency virus 1 by both cysteine-dependent and cysteineindependent mechanisms.1991. Proc Natl Acad Sci U S A 88 (13):5552-6.
Carubelli R, Schneider Jr JE, Pye QN and Floyd RA. 1995. Cytotoxic effects of
autoxidative glycation. Free Radic Biol Med 18 (2):265-9.
Avery SV, Howlett NG and Radice S. 1996. Copper toxicity towards
Saccharomyces cerevisiae: dependence on plasma membrane fatty acid
composition. Appl Environ Microbiol 62 (11):3960-6.

Tanaka KH, Iguchi S, Taketani R, Nakata S, Tokumaru S, Sugimoto T and Kojo S.

Facile degradation of apolipoprotein B by radical reactions and the presence of
cleaved proteins in serum. 1999. J Biochem (Tokyo) 125 (1):173-6.
Kim JH, Cho H, Ryu SE and Choi MU. Effects of metal ions on the activity of
protein tyrosine phosphatase VHR: highly potent and reversible oxidative
inactivation by Cu2+ ion. 2000. Arch Biochem Biophys 382 (1):72-80.
Fernandes AR, Prieto M and Sa-Correia I. 2000. Modification of plasma
membrane lipid order and H+-ATPase activity as part of the response of
Saccharomyces cerevisiae to cultivation under mild and high copper stress.
Arch Microbiol 173 (4):262-8.
EU Risk Assessment [Copper, Copper II sulphate pentahydrate, Copper(I)oxide,
Copper(II)oxide, Dicopper chloride trihydroxide]. In EU Voluntary Risk
Assessment, edited by RC Italy, CDR Binetti. European Copper Institute. 2006.
Grass G, Rensing C and Solioz M. Metallic Copper as an Antimicrobial
Surface. Minireview, Applied and Environmental Microbiology, Mar. 2011,
pp. 15411547 Vol. 77, No. 5.
Warnes SL and Keevil CW. Mechanism of copper surface toxicity in
Vancomycin-resistant enterococci following wet or dry surface contact.
Applied and Environmental Microbiology, Sept. 2011. pp. 60496059.
Mathews S, Hans M, Mcklich F, Solioz M. Contact killing of bacteria on
copper is suppressed if bacterial-metal contact is prevented and is induced
on iron by copper ions. Appl Environ Microbiol. 2013 Apr;79(8):2605-11. doi:
10.1128/AEM.03608-12. Epub 2013 Feb 8.

Health Economics Assessment

The Economic Assessment of an Environmental Intervention: Discrete
Deployment of Copper for Infection Control in ICUs. M Taylor, S Chaplin, York
Health Economics Consortium, York, UK, Antimicrobial Resistance and
Infection Control 2013, 2(Suppl1):P368.

Copper Voluntary Risk Assessment

The Copper Voluntary Risk Assessment - A Pioneering Industry/Member State
Partnership Approach to Duty of Care. Istituto Superiore di Sanita and
European Copper Institute. 2008.

Pena M, Lee MJ and Thiele DJ. A delicate balance: homeostatic control of

copper uptake and distribution. 1999. J Nutr 129 (7):1251-60.

11

Appendix 1: YHEC Business Case Model Worked Example - Intensive Care Unit, UK
Parameter

Value

Note

Number of beds

20

Single room configuration.

Number of patients per annum

1,200

Based on an average stay of 6 days (Edbrooke 2011).

Infection rate (all HCAIs)

25%

27.1% in Cairns 2010.

23.4% in English National Point Prevalence Survey on Healthcare, Health Protection Agency
(2012).

Cost per HCAI

6,000

Negrini (2006) reported the average cost per patient-day over 75 UK ICUs was $1,512 (1,000) and
an HCAI results in an additional 6 days. While the model allows for costs of subsequent outpatient
and GP visits to be taken into account, these are not considered here.

Items to be upgraded to copper (or

antimicrobial copper alloy)

6 critical items:
IV drip pole
Bed rails
Computer input device
Nurse call button
Over-bed table
Visitor chair

Schmidt MG, Copper Touch Surface Initiative. Microbiology and Immunology, Medical
University of South Carolina, Charleston, USA, BMC Proceedings 2011, 5(Suppl 6):O53 (Oral
presentation delivered at 1st International Conference on Prevention and Infection Control,
June 29-July 2, 2011, Geneva, Switzerland).
Sustained Reduction of Microbial Burden on Common Hospital Surfaces through Introduction
of Copper, Michael G Schmidt et al, Journal of Clinical Microbiology, July 2012, Vol 50, No 7.
This study was conducted in single-room ICUs. Other key touch surface replacements are also
available - such as door handles, push plates, taps - that comply with current hospital
regulatory requirements, and have been identified as high risk touch surfaces in other clinical
areas.

Cost of intervention

30,600

This is the cost difference between copper and standard, non-antimicrobial components, using
early market prices. As this example is based on a new build or planned renovation, installation
costs would be similar and have therefore not been considered.

Reduction in HCAIs post intervention

20%

Copper Surfaces Reduce the Rate of Healthcare-Acquired Infections in the Intensive Care Unit,
Cassandra D Salgado et al, Infection Control and Hospital Epidemiology, May 2013, Vol 34, No 5.
This study demonstrated a 58% reduction in infections in ICU rooms equipped with copper.
The example below uses a conservative figure of 20%.

5 Year Results
Using the above inputs, the model yields a return on investment of less than two months. The cost of copper components is 105,000 compared
to 74,400 for standard items. There were 1,200 infections in the copper group and 1,500 in the baseline. This results in a cost per infection
averted of 102. The model calculates additional benefits including bed days freed and Quality-Adjusted Life Years. To download the model visit
www.antimicrobialcopper.com/uk/why-antimicrobial-copper/the-business-case.aspx or email info@copperalliance.org.uk.

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Dominant means that Antimicrobial Copper is

both the cheaper and the more effective option

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www.antimicrobialcopper.org